Discussing weight loss opportunistically and effectively in family practice: a qualitative study of clinical interactions using conversation analysis in UK family practice

The Basis of Patient Resistance to Opportunistic Discussions About Weight in Primary Care

Clinicians expect that talking to patients with obesity about potential/future weight loss will be a difficult conversation, especially if it is not the reason that a patient is seeking medical help. Despite this expectation, many governments ask clinicians to take every opportunity to talk to patients about weight to help manage increasing levels of obesity. Although this is recommended, little is known about what happens in consultations when clinicians opportunistically talk to patients about weight, and if the anticipated difficulties are reality. This paper examines displays of explicit patient resistance following opportunistic weight-loss conversations initiated by GPs. We analyzed audio recordings and transcribed them for conversation analysis. We focused on the precursors of explicit resistance displays during opportunistic weight loss discussions, the format of the resistance, and the ways it was managed by GPs. We found relatively few instances of explicit resistance displays. When it did occur, rather than be related to the opportunistic nature of the advice, or the topic of weight itself, resistance was nuanced and associated to the sensitivity of the GPs managing unknown patient levels of awareness of weight loss benefits, or prior efforts to lose weight. Clinicians tended not to challenge this resistance from patients, and we suggest this tactic may be acceptable to patients and help foster the long-term collaborative relationships needed to tackle obesity. Data are in British English.

Participants' perspectives of being recruited into a randomised trial of a weight loss intervention before colorectal cancer surgery: a qualitative interview study

BACKGROUND

The period between cancer diagnosis and surgery presents an opportunity for trials to assess the feasibility of behaviour change interventions. However, this can be a worrying time for patients and may hinder recruitment. We describe the perspectives of patients with excess weight awaiting colorectal cancer surgery about their recruitment into a randomised trial of a prehabilitation weight loss intervention.

METHODS

We interviewed the first 26 participants from the 8 recruitment sites across England in the 'CARE' feasibility trial. Participants were randomised into either usual care (n = 13) or a low-energy nutritionally-replete total diet replacement programme with weekly remote behavioural support by a dietitian (n = 13). The semi-structured interviews occurred shortly after recruitment and the questions focused on participants' recollections of being recruited into the trial. We analysed data rapidly and then used a mind-mapping technique to develop descriptive themes. Themes were agreed by all co-authors, including a person with lived-experience of colorectal surgery.

RESULTS

Participants had a mean body mass index (± SD) of 38 kg/m2 (± 6), age of 50 years (± 12), and 42% were female. People who participated in the trial were motivated by the offer of structured weight loss support that could potentially help them improve their surgical outcomes. However, participants also had concerns around the potential unpalatability of the intervention diet and side effects. Positive attitudes of clinicians towards the trial facilitated recruitment but participants were disappointed when they were randomised to usual care due to clinical teams' overemphasis on the benefits of losing weight.

CONCLUSIONS

Patients were motivated to take part by the prospect of improved surgical outcomes. However, the strong preference to be allocated to the intervention suggests that balanced communication of equipoise is crucial to minimise disappointment from randomisation to usual care and differential dropout from the trial.

CLINICAL TRIAL REGISTRATION

ISRCTN39207707, Registration date 13/03/2023.

What advice do general practitioners give to people living with obesity to lose weight? A qualitative content analysis of recorded interactions

BACKGROUND

Guidelines recommend general practitioners (GPs) take every opportunity to talk to people living with obesity about their weight, and evidence shows even very brief advice is associated with weight loss. However, little is known about what GPs say when giving brief behavioural advice, and if it reflects evidence-based recommendations for people living with obesity. To understand what behavioural advice GPs give, we categorized the content and delivery of GPs' advice during brief interventions.

METHODS

Qualitative content analysis was applied to 159 audio recordings of consultations from the Brief Interventions for Weight Loss (BWeL) trial, where GPs gave brief weight-loss advice to patients with a body mass index ≥30 kg/m2 (or ≥25 kg/m2 if Asian) in 137 UK surgeries. Similar content was grouped into descriptive clusters.

RESULTS

The results comprised 4 clusters, illuminating different aspects of the advice given: (i) Content of diet and physical activity advice, showing this was highly varied; (ii) Content of "implementation tips" given to support changes, e.g. using smaller plates; (iii) Content of signposting support, either towards further clinician support, or other resources, e.g. information booklets; (iv) Style of advice delivery, showing GPs rarely gave personalized advice, or reasons for their advice.

CONCLUSIONS AND IMPLICATIONS

Weight-loss advice from GPs to patients with obesity rarely included effective methods, mostly communicating a general "eat less, do more" approach. Advice was mostly generic, and rarely tailored to patients' existing knowledge and behaviours. Effectiveness of brief weight-loss advice could be improved if GPs were given clearer guidance on evidence-based recommendations.

A Qualitative Exploration of Patient and Staff Experiences of the Receipt and Delivery of Specialist Weight Management Services in the UK

BACKGROUND

Addressing the increasing prevalence of obesity is a global public health priority. Severe obesity (body mass index > 40) reduces life expectancy, due to its association with people developing complications (e.g. diabetes, cancer, cardiovascular disease), and greatly impairs quality of life. The National Health Service (NHS) in the UK provides specialist weight management services (SWMS) for people with severe obesity, but key uncertainties remain around patient access to and engagement with weight management services, as well as pathways beyond the service.

METHODS

In this multiple methods study, using online forum data and semi-structured interviews, stakeholders' experiences of delivering and receiving SWMS were explored. Using the web search engine Google with keywords and web address (URL) identifiers, relevant public online platforms were sourced with snowball sampling and search strings used to identify threads related to people's experiences of accessing SWMS (n = 57). Interviews were conducted with 24 participants (nine patients, 15 staff), and data from all sources were analysed thematically using the framework approach.

RESULTS

Six themes related to access to and engagement with SWMS emerged during data analysis: (1) making the first move, (2) uncertainty and confusion, (3) resource issues, (4) respect and understanding, (5) mode of delivery, and (6) desire for ongoing support.

CONCLUSION

There is a mixed and varied picture of SWMS provision across the UK. The service offered is based on local clinical decision making and available resources, resulting in a range of patient experiences and perspectives. Whilst service capacity issues and patient anxiety were seen as barriers to accessing care, peer support and positive clinical and group interactions (connectedness between individuals) were considered to increase engagement.

Anticipated barriers and enablers to signing up for a weight management program after receiving an opportunistic referral from a general practitioner

Introduction

General Practitioners (GP) are advised to opportunistically refer patients with overweight or obesity to a tier 2 weight management program, but few patients sign up after receiving the referral. Signing up to a weight management program is a behaviour, as such, behaviour change interventions are needed to increase sign ups. However, no research has explored the influences on signing up after an opportunistic referral specifically.

Aim

To investigate the influences (i.e., barriers and enablers) on signing up to a tier 2 weight management service after receiving an opportunistic referral from a GP, using a theoretical framework to inform intervention development.

Method

Semi-structured interviews were conducted with 18 residents from the London borough of Hounslow who were eligible for the service. Interview guides were informed by the Theoretical Domains Framework (TDF). Data were analyzed inductively using Reflexive Thematic Analysis and Coding Reliability to identify influences on signing up, before being deductively coded to the TDF and grouped into themes.

Results

Eight theoretical domains were identified as influences on signing up. Fifteen sub-themes were developed and categorized as either a barrier (5), enabler (3), or mixed (7) influence. Beliefs about Consequences was the most frequently reported influence on signing up. Beliefs that were expressed the most often include how effective the program would be, whether the program is needed to lose weight and whether the program would be compatible with their lifestyle. Leveraging Social Influences and changing patient's Knowledge could address these beliefs and provide a potential route for Behaviour change.

Discussion

The present study provides the first insight into behavioural influences on signing up for a weight management service opportunistically using a validated theoretical framework. This study has implications for intervention development in that public health researchers can identify intervention, content and implementation options based on the findings. Interventions targeting the key domains of Knowledge, Social influences and Beliefs about consequences would likely be the most effective because of their prominence and influence on other domains.

The #longcovid revolution: A reflexive thematic analysis

Research has identified long COVID as the first virtual patient-made condition (Callard and Perego, 2021). It originated from Twitter users sharing their experiences using the hashtag #longcovid. Over the first two years of the pandemic, long COVID affected as many as 17 million people in Europe (WHO, 2023). This study focuses on the initial #longcovid tweets in 2020 (as previous studies have focused on 2021-2022), from the first tweet in May to August 2020, when the World Health Organization recognised the condition. We collected over 31,000 tweets containing #longcovid from Twitter. Using Braun and Clarke's reflexive thematic analysis (2020), informed by the first author's experience of long COVID and drawing on Ian Hacking's perspective on social constructionism (1999), we identified different grades of social constructionism in the tweets. The themes we generated reflected that long COVID was a multi-system, cyclical condition initially stigmatised and misunderstood. These findings align with existing literature (Ladds et al., 2020; Rushforth et al., 2021). We add to the existing literature by suggesting that Twitter users raised awareness of long COVID by providing social consensus on their long COVID symptoms. Despite the challenge for traditional evidence-based medicine to capture the varied and intermittent symptoms, the social consensus highlighted that these variations were a consistent and collective experience. This social consensus fostered a collective social movement, overcoming stigma through supportive tweets and highlighting their healthcare needs using #researchrehabrecognition. The #longcovid movement's work was revolutionary, as it showed a revolutionary grade of social constructionism, because it brought about real-world change for long COVID sufferers in terms of recognition and the potential for healthcare provisions. Twitter users' accounts expose the limitations of traditional evidence-based medicine in identifying new conditions. Future research on novel conditions should consider various research paradigms, such as Evidence-Based Medicine Plus (Greenhalgh et al., 2022).

GP delivered brief weight loss advice: associations between in-consultation behaviour change techniques and patient weight loss in recorded primary care discussions

Background

Primary care clinicians are encouraged to intervene opportunistically, offering weight-loss advice to people living with obesity. The BWeL trial showed patients receiving brief weight-loss advice from their general practitioner lost weight at one year follow-up. We examined the behaviour change techniques (BCTs) clinicians used to identify which BCTs are associated with this weight loss.

Methods

We coded 224 audio recorded interventions from the BWeL trial using the behavioural change techniques version one taxonomy (BCTTv1) and the 'refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours' (CALOR-RE taxonomy). Linear and logistic regressions were performed to analyse associations between behaviour change techniques used in these taxonomies and patient weight loss.

Results

Mean intervention length was 86 s. We identified 28 different BCTs BCTTv1 and 22 from CALOR-RE. No BCTs or BCT domains were associated with mean weight loss at 12 months, loss of 5% bodyweight, or action taken at 3 months. The BCT 'Feedback on outcomes of behaviour (future)' was associated with an increased likelihood that the patient reported taking action to lose weight by 12 months (OR = 6.10, 95%CI = 1.20, 31.0).

Conclusion

Although we found no evidence to support the use of particular BCTs, our results suggest that it is the brief intervention itself, rather than specific content, which may motivate weight loss. This can support clinicians to confidently intervene without needing complex training. Offering follow-up appointments can support positive changes to health behaviours, even if these are not associated with weight loss.

Influences on Patient Uptake of and Engagement With the National Health Service Digital Diabetes Prevention Programme: Qualitative Interview Study

BACKGROUND

Digital diabetes prevention programs (digital-DPPs) are being implemented as population-based approaches to type 2 diabetes mellitus prevention in several countries to address problems with the uptake of traditional face-to-face diabetes prevention programs. However, assessments of digital-DPPs have largely focused on clinical outcomes and usability among those who have taken them up, whereas crucial information on decision-making about uptake (eg, whether a user downloads and registers on an app) and engagement (eg, the extent of use of an app or its components over time) is limited. Greater understanding of factors that influence uptake and engagement decisions may support large-scale deployments of digital-DPPs in real-world settings.

OBJECTIVE

This study aimed to explore the key influences on uptake and engagement decisions of individuals who were offered the National Health Service Healthier You: Digital Diabetes Prevention Programme (NHS-digital-DPP).

METHODS

A qualitative interview study was conducted using semistructured interviews. Participants were adults, aged ≥18 years, diagnosed with nondiabetic hyperglycemia, and those who had been offered the NHS-digital-DPP. Recruitment was conducted via 4 providers of the NHS-digital-DPP and 3 primary care practices in England. Interviews were conducted remotely and were guided by a theoretically informed topic guide. Analysis of interviews was conducted using an inductive thematic analysis approach.

RESULTS

Interviews were conducted with 32 participants who had either accepted or declined the NHS-digital-DPP. In total, 7 overarching themes were identified as important factors in both decisions to take up and to engage with the NHS-digital-DPP. These were knowledge and understanding, referral process, self-efficacy, self-identity, motivation and support, advantages of digital service, and reflexive monitoring. Perceptions of accessibility and convenience of the NHS-digital-DPP were particularly important for uptake, and barriers in terms of the referral process and health care professionals' engagement were reported. Specific digital features including health coaches and monitoring tools were important for engagement.

CONCLUSIONS

This study adds to the literature on factors that influence the uptake of and engagement with digital-DPPs and suggests that digital-DPPs can overcome many barriers to the uptake of face-to-face diabetes prevention programs in supporting lifestyle changes aimed at diabetes prevention.

Autonomy-supportive decision-making in maternity care during prenatal consultations: a qualitative interaction analysis

OBJECTIVES

The aim of this study was to identify mechanisms of autonomy-supportive consultation (ASC) that maternity care professionals use during decision-making in prenatal consultations.

DESIGN

This study was a descriptive, qualitative analysis of professional-patient interactions in maternity care, using concepts and analytic procedures of conversation analysis.

SETTING

The prenatal consultations took place in hospitals and midwifery practices in the Netherlands. This study was part of a larger project. For the current study, we selected prenatal consultations concerning three topics in which patients make their own choices.

PARTICIPANTS

The first author invited the patient who was waiting in the waiting room. Participants were not selected a priori.

MAIN OUTCOME MEASURES

The main outcome measures were mechanisms of ASC.

RESULTS

We selected 20 consultations which were conducted by 20 different professionals. We found eight mechanisms in the professional-patient interaction which were categorised into three overarching themes. The first theme, 'Lightheartedness', comprises the interactional mechanisms 'minimising language' and 'humour'. The theme 'Orientation to agreement' describes how professionals and patients seem to be oriented towards demonstrating agreement and mutual understanding. The last theme, 'Offering information and options', describes the professional formally giving factual information almost completely without verbal interaction between the professional and the patient.

CONCLUSION

The results of this study show that the model of ASC can be enriched by adding minimising language and humour to the mechanisms that can be used to fulfil the psychological need 'relatedness'. Second, our results show that professionals use only few mechanisms to meet the patients' psychological needs 'competence' and 'autonomy'. They mainly use information giving to meet patients' need competence. To meet patients' need for autonomy, the professionals keep all options open. This suggests that professionals could pay more attention to other mechanisms to meet patients' needs for 'competence' and 'autonomy'.

Making Conversation Analysis Accessible: A Conceptual Guide for Health Services Researchers

The quality of healthcare communication can impact both experiences and outcomes. We highlight aspects of communication that can be systematically examined using Conversation Analysis (CA) and provide guidance about how researchers can incorporate CA into healthcare studies. CA is a qualitative method for studying naturally occurring communication by analyzing recurrent, systematic practices of verbal and nonverbal behavior. CA involves examining audio- or video-recorded conversations and their transcriptions to identify practices speakers use to communicate and interpret behavior. We explain what distinguishes CA from other methods that study communication and highlight three accessible CA approaches that researchers can use in their research design, analysis, or implementation of communication interventions. Specifically, these approaches focus on how talk is produced (specific words, framing, and syntax), by whom, and when it occurs in the conversation. These approaches can be leveraged to generate hypotheses and to identify patterns of behavior that inform empirically driven communication interventions.